Health care fraud, waste and abuse are major problems. They can make taxes go up. They can cause quality of care issues. Molina Healthcare of New Mexico, Inc. (Molina Healthcare) works with state and federal agencies to detect, prevent and put a stop to these kinds of crimes.
State and federal laws require Molina Healthcare to report fraud, waste and abuse. Cases are sent to the government and/or law enforcement for investigation.
Why is it Important to Have an Anti-Fraud Program?
Health care fraud, waste and abuse is against the law. The Anti-Fraud program looks at these issues. They can harm the health plan. They can impact our ability to care for you.
The role of the Anti-Fraud program is to:
- Investigate; and
What is Fraud?
Fraud is an unfair or unlawful act. Fraud is done on purpose to get something of worth.
What is Waste?
Health care spending that is not necessary for appropriate quality of care. Waste can include overuse, underuse, ineffective use, or doing more than what is needed.
What is Abuse?
Abuse happens when things are not done in line with good financial, business or medical practices. This can result in unnecessary costs and can result in payment for services that are not medically necessary. It can result in services that fail to meet professionally recognized standards for health care.
Who commits Fraud, Waste and Abuse?
Anyone can commit fraud, waste or abuse. This can include providers and members.
- Altering claims, electronic forms and/or medical records in order to get a higher payment;
- Asking for, offering, or getting a kickback, bribe, or rebate;
- Balance billing happens when a provider bills a member for all charges not paid for by the health plan;
- Billing a procedure that does not match the diagnosis or problem;
- Billing for services that did not happen;
- Billing for services using a Provider's name that did not provide the care;
- Billing the wrong place of service in order to get payment or get a higher payment;
- Completing medical forms for Members not known by the Provider;
- False coding in order to get payment or get a higher payment;
- Charging members for drug samples;
- Having members come in for office visits more often than is needed;
- Not billing coding modifiers the right way in order to get payment or get a higher payment;
- Questionable prescription practices;
- Questionable transportation services;
- Unbundling services in order to get more payment. This involves splitting a procedure into parts and charging for each part rather than using a single code;
- Underutilization means failing to provide services that are medically necessary;
- Upcoding happens when a provider does not bill the right code for the service and uses a code for a like service that costs more; and
- Waiving co-payments.
- Abusing transportation benefits (e.g. using ambulance services for non-emergencies);
- Doctor shopping in order to get services that are not needed;
- Drug seeking behavior;
- Drug trafficking;
- Giving false information;
- Identity theft;
- Not paying co-payments;
- Not giving information to Molina Healthcare about other insurance coverage;
- Theft; and
- Using someone else's medical card.
Reporting Fraud, Waste and Abuse
Anyone with information about possible fraud, waste and abuse can make a referral. Referrals are sent to the Anti-Fraud program. You can make a referral, without giving your name. Information reported to the Anti-Fraud program will remain confidential to the extent possible as allowed by law.
Molina Healthcare does not allow or tolerate retaliation against those, who in good faith, report potential fraud, waste and abuse to the Anti-Fraud program.
You may report suspect activity. You can do this in writing or by phone.
Anti-Fraud Program Manager
Molina Healthcare of New Mexico
P.O. Box 3887
Albuquerque, NM 87190-9859
Toll free Compliance & Anti-Fraud Hotline: (800) 827-2973
In Albuquerque: (505) 341-7469
Toll free fax: (866) 472-4580
Give as much information as you can when making a referral. The Anti-Fraud program needs to know:
- Who is the suspect?
- What is the suspect's name?
- When did the possible fraud, waste and abuse happen?
- Where did the possible fraud, waste and abuse happen?
- Why do you think the possible fraud, waste and abuse happened?
- How did the possible fraud, waste and abuse happen?
The more detail you can give the Anti-Fraud program the better. This improves the chances the issue will be successfully reviewed and resolved.
You can also report fraud, waste and abuse to:
Medical Assistance Division
Quality Assurance Bureau
P.O. Box 2348
Santa Fe, NM 87504-2348
Toll free: (888) 997-2583
In Santa Fe: (505) 827-3100.
Medicaid Fraud Control Unit
111 Lomas NW, Suite 300
Albuquerque, NM 87102
Toll free: (800) 678-1508
In Albuquerque: (505) 222-9000.
New Mexico Human Services Department
Office of Inspector General
Toll free: (800) 228-4802
In Albuquerque: (505) 827-8141.
Such services are funded in part under contract with the State of New Mexico.
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